Application for Employment

930 Interchange Drive Holland, MI 49423

*=Required Fields

Personal Info

Your Name*
 
 
Your Email
Today's Date*
Are you legally eligible for employment
in the United States?*
Your Street Address*
City*
State*
Zip Code*
Home Phone
Cell Phone*
Date of Birth*
If you have not lived at the above address for at least three years? Please list below all additional residences during that time.
Street Address
City
State
Zip Code
From
To

Click on the plus (+) button to add addresses as necessary.
Driver's License Info

State Issued*
CDL Class*
Endorsements*
Expiration Date*
List previous states where you have held a driver's license*
Driving Experience

Have you ever been bonded?*
If "yes," with what employers?
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*
Has any license, permit, or privilege ever been suspended or revoked?*
List states operated in for the last five years*
List type of equipment you have operated
and are competent to drive*
Which safe driving awards do you
hold and from whom?*
Accident record for the past 3 years or more. If none, write "none."*
Date:
Nature of Accident:
Fatalities:
Injuries:
Traffic Convictions and forfeitures for the past 3 years (Other than parking violations). If none, write "none."*
Location:
Date:
Charge:
Penalty:
Have you ever been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by court?
Application Info

Position Applying For*
Who Refered You?
Type of Employment*
use ctrl+click (cmd+click) to select multiple options
Expected Pay Rate
Are you currently employed*
How long since your last employment
When will you be available to begin work?
Will you work overtime if asked?*
Education Info

Highest grade completed*
College*
Graduate School*
Last School Attended*
 
 
Course of Training
Did you graduate?*
Degree or Diploma*
What year?
Other special training or skills?
Military Service

Did you serve in the U.S. Armed Forces?*
Employment History

All driver applicants for interstate commerce must provide the following information on all employer's during the preceding three(3) years. Your past employer's complete mailing address and phone numbers. Applicants to drive commercial motor vehicle (having GVWR for 20,601 lbs. or more, or any size vehicle used to transport hazardous materials in a quantity requiring placarding) in intrastate or interstate commerce shall also provide an additional seven (7) years of information on those employers for whom the applicant operated such a vehicle.

Note: List employers in reverse order starting with the most recent.
Employer Name*
Telephone
Address*
Employed*
(month and year)
Name of Supervisor
Weekly Pay
 
Your Job Title*
May we contact this employer?*
Job Description
Reason for Leaving

Click on the plus (+) button to add employers as necessary.
Applicant Must Read and Sign

I hereby certify that the facts set forth in the completed employment application are true and complete to the best of my knowledge. I understand that if employed, falsified statements on this application may result in dismissal. I understand that as an applicant for a position with Teddy's Transport, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I agree to furnish such additional information and complete such examinations which may be material to my qualifications for service now and, if applicable, during the tenure of my employment or service.

I hereby authorize Teddy's Transport and/or its agents to make independent investigation which may include, but is not limited to the following areas: verification of social security number, current and previous residences, employment history, education background, character references, drug and alcohol testing, accident history, safety performance, civil and criminal history records from any criminal justice agency in or all federal, state, county jurisdictions, driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation or public agency (including the Social Security administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to Teddy's Transport, or its agents.

I hereby release Teddy's Transport and its agents and any person or entity, which provides information pursuant to this authorization to release, from any and all liabilities, claims or law suits in regards to the information obtained from any and all of the above referenced sources used.

By typing your full name and clicking the checkbox you are submitting this document, affirming to Teddy's Transport by digital signature, that all of the information being sent is correct and accurate for the above application form.

Signature*
Signed Date*
Background Report Disclosure

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE
PSP Online Service

In connection with your application for employment with Teddy's Transport ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Administration (FMCSA) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Teddy's Transport ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSA violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

By typing your full name and clicking the checkbox you are submitting this document, affirming to Teddy's Transport that you understand and authorize by digital signature pre-employment background report access.

Signature*
Signed Date*

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's consent. The language must be used in whole, exactly as provided. Further, the language on this fonn must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

LAST UPDATED 12/22/2015

DOT Drug/Alcohol Test Results

Applicant Authorization to Release DOT Drug/Alcohol Test Results

(As required by 49 CFR Parts 40.25 and 391.23)

TO BE COMPLETED BY APPLICANT

I, , as the "Applicant," understand that as a condition of hire with Teddy's Transoprt, as the "Company", I must consent to the release of all DOT mandated drug and alcohol information from all of the employers for which I worked in a DOT safety-sensitive position, or for which I took a DOT pre-employment drug test, during the previous three (3) years as required by Part 391.23 for any driver of a commercial motor vehicle). Below, I have listed all of the employers for which I have worked during the past three years (as a CDL driver). I hereby authorize all of my previous employers listed below to furnish to the company, listed above, the DOT information described below.

A Commercial Driver's License (CDL) is required for my employment:
(If Yes, provide all DOT previous employers in the past 3 years.)


Previous DOT Employer
Telephone
Fax
Address
Employed
(month and year)


Applicant Certification: I have read and fully understand this authorization to release my previous drug and alcohol test information, identified by the check boxes below, lo the company listed above. In signing below, I certify that all of the Information I have furnished on this form is true and complete, and that I have identified all of the employers for which I have worked in a DOT safety-sensitive position during the previous three years. I also understand that I am responsible for all costs associated with any pending Substance Abuse Professional assessment, recommendations, education and treatment, including costs involving return-to-duty testing and follow-up testing yet to be completed.

Have you performed DOT functions in the past three years (as a CDL driver.)?*

Have you tested positive, or refused to test, on any DOT pre-employment drug or alcohol test for an employer who did not hire you during the past three years?*

By typing your full name and clicking the checkbox you are submitting this document, affirming to Teddy's Transport that you understand and authorize by digital signature the release of DOT drug/alcohol test results from your previous employers.
Signature*
Signed Date*